Clinical Procedures and Safe Clinical Practice Acupuncture NZ is committed to ensuring that all members adhere to the Rules of the organisation and abide by the Acupuncture NZ Code of Professional Ethics. It is expected that all members maintain a clean and safe environment for their patients at all times, ensuring that all equipment used is appropriate to the task and maintained to a high standard. The aim of this document is to provide guidelines to assist in the safe delivery of treatment and in minimising the occurrence of potential adverse events. Every year Acupuncture NZ will randomly select a number of clinics throughout the country and appropriately trained assessors will visit the practitioner/s to ensure that expected standards are being maintained. This document was reviewed in February 2016 and will again be reviewed by February 2019. 1
Contents 1 Clinical premises requirements 2 Informed consent 3 Skin piercing - needle manipulation and handling - Precautions when needling - Contraindications to needling 4 Management of needle accidents - Fainting during needle insertion or manipulation - Stuck needle - Bent needle - Broken needle - Bruising and bleeding - Seizures - Pneumothorax - Needle stick injury to Practitioner 5 Press needles and intradermal needles 6 Management of sharps and waste 7 Moxibustion - Precautions before applying moxibustion - Contraindications for moxibustion 8 Heat lamps and hot packs 9 Cupping - Precautions for cupping - Contraindications for cupping 10 Electro-acupuncture - Precautions for electro-acupuncture - Contraindications for electro-acupuncture 11 Laser acupuncture - Precautions for the use of laser acupuncture - Contraindications for laser acupuncture 12 Bloodletting and using a dermal hammer - Precautions for bloodletting and using a dermal hammer - Contraindications for bloodletting and using a dermal hammer 13 Thread embedding - Precautions for thread embedding - Contraindications for thread embedding 14 Herbal preparations - Precaution for herbal preparations - Contraindications for herbal preparations 15 Medicinal patches - Before use - Precautions when using medicinal patches - Contradictions when using medicinal patches 16 Injury to organs signs, symptoms and possible causes - Lungs - Liver and Spleen - Kidneys - Brain and spinal cord 17 Incident reporting form 18 Informed consent form specified conditions 2
1 Clinical Premises Requirements The premises must be suitable for an acupuncture clinic. Premises must be kept in good repair and kept clean, tidy and hygienic. This includes floors, walls, windows, furniture, light shades as well as the area used for acupuncture. Acupuncture NZ members are responsible for meeting the requirements of their local Council bylaws. Premises must meet the following requirements: Access Patients must be able to get into the clinic easily. If there are steps they must be stable, not too steep and with an appropriate handrail. Heating, light and ventilation Clinic space must be warm, well-lit and have adequate ventilation. If moxa is being used then a window must be able to be opened, or an extraction fan or air conditioner available to clear any smoke. Linen and soft furnishings All towels, sheets, blankets, pillows and pillow cases must be clean and tidy and regularly laundered. Any furniture coverings must be clean and in good repair. Toilets and hand basins Toilets and hand basins must be easily accessible, hygienic, clean and tidy. The use of a liquid soap dispenser and paper towels is recommended. Waste disposal Approved sharps container must be in the immediate vicinity of all treatment areas, and lined bins used for all other waste. Bins must be emptied regularly. Fire safety and fire extinguisher Fire exits must be clearly marked and free of any obstruction. A fire extinguisher should be readily at hand. 2 Informed consent For each treatment all patients should be informed of the purpose, benefits and possible risks of treatment, including adverse reactions to treatment. This allows the patients to make up their own mind as to whether to commence treatment or not. Practitioners should explain the different procedures throughout the treatment and seek the permission of the patient to continue. Informed consent is both a legal and ethical requirement. Additionally, a specific Informed Consent form must be completed by the patient and practitioner prior to the administration of the following five treatment protocols: dermal hammering, gua sha, thread embedding, scarring moxa, bleeding. (see Section 18 on page 13) Patients have the right to refuse treatment, advice or examination procedures. They also have the right to ask the practitioner to stop any procedure once it has begun. 3 Skin piercing needle manipulation and handling Because acupuncture needles penetrate the skin it is essential that practitioners take every necessary precaution to prevent the transmission of blood borne diseases. Needle manipulation and handling must be aseptic at all times. 3
This requires that all members of Acupuncture NZ must: - Use pre-sterilised single use needles - Wash hands for at least 20 seconds using soap before and after treating a patient - Antiseptic hand gel is acceptable where it is impracticable to wash hands with soap and water ie at an outside event where treatment is being offered - If using alcohol swabs, a new sterile swab must be used for each patient - Remove the needle from the packaging by grasping only the handle of the needle and avoid touching the shaft - Insert the needle swiftly and with correct needle technique - Needles must not be inserted through clothing, strapping tape or wound dressings - After completing treatment, remove the needle and place it into a medical sharps container immediately the sharps container must be in the immediate vicinity of the patient - Follow required procedures if needle stick injury should occur (see relevant section 'Procedure for needle stick injury') Precautions when needling - Pregnant women: Certain acupuncture points are to be used with caution during pregnancy. LI4 Hegu, SP6 Sanyinjiao, GB21 Jianjing, BL60 Kunlun and BL67 Zhiyin. However, these points may be useful for the purpose of encouraging labour or shortening its duration. In addition, caution must be used on any points on the abdomen below the umbilicus or on the lumbo-sacral region. After the first trimester, caution is also required for any abdominal points above the umbilicus. - Infants heads: acupuncture points on the head should not be needled if the fontanelles are not closed - People with bleeding disorders and those on blood thinning medications as bleeding may occur when a needle is removed. Pressure should be applied using a clean swab over the point. Contraindications to needling - Acupuncture should not be carried out if the patient is under the influence of alcohol or recreational drugs - Needles must not be administered to open wounds or infected areas - Needles must not be administered through clothing, strapping tape or wound dressings - Needles must not be applied directly into known tumour sites 4 Management of needle accidents Fainting during needle insertion or manipulation - If a patient faints withdraw any needles already in place - Ensure that the patient is lying down and in a position to recover safely - Check airways, breathing and circulation - Finger pressure may be applied to appropriate points such as GV 26 shuigou, PC9 zhangchong, LI4 Hegu, or KD1 Yongquan - If the patient is not breathing call for an ambulance and follow appropriate First Aid precautions Stuck needle - Leave needle in place for a few minutes (it may loosen by itself) - Tap or massage around the point - Administer a second needle close to the needle that cannot be removed - Gentle moxa may be applied to the area around the needle 4
Bent needle - If the patient has moved causing the needle to bend, very slowly remove the bent needle following the angle of the bend - Avoid the use of force when removing a bent needle Broken needle - If broken above the skin (between handle and shaft), use tweezers to pull the needle out immediately - If broken at skin level gently push down surrounding skin and remove with tweezers - If broken deep in the tissue mark a circle around point of insertion, immobilise the body part and transfer the patient to hospital Bruising and bleeding - It is relatively common for slight bruising or bleeding to occur when an acupuncture needle is removed - Apply direct pressure with a clean swab or cotton ball until the bleeding has stopped Seizures - If the patient is unconscious, remove any needles and manage in accordance with current First Aid procedures - Finger pressure may be applied to points such as Du26 Shuigou, LI4 Hegu or KD1 Yongchuan - Refer the patient to their GP or the nearest hospital Pneumothorax - If a pneumothorax is suspected (signs may include chest pain, tightness, dry cough, shortness of breath on exertion) remove needles immediately and call 111 for an ambulance - Symptoms of a pneumothorax may not become apparent until some time after an acupuncture treatment, so if a patient calls with any of the above symptoms advise them to immediately go to the Emergency Department of their nearest hospital - Complete an Incident Report and forward to Acupuncture NZ - Contact the patient later that day or the following day to check on their condition Needle stick injury to practitioner - Remove the needle immediately - Apply pressure around the area to promote bleeding - Swab the area with alcohol; if alcohol not available wash thoroughly with soap and warm water - Ensure the incident is documented, including date, time and the name of the patient who had been needled - Seek medical care, such as undergoing an HIV and hepatitis antibody test 5 Press needles and intradermal needles - Only single use pre-sterilised press needles may be used. The same levels of hygiene are to be maintained as for all needling - The procedure must be fully explained to the patient, informing them to remove the needle should it become uncomfortable or irritating 5
6 Management of sharps and waste - After removal from the patient, all needles are to be placed directly into an approved sharps container - The sharps container must be in the immediate vicinity of the patient - The sharps containers should be filled only to the recommended level - A recognised collection agency must be used to dispose of the filled sharps containers - When the sharps containers are being moved the lids should be firmly in place - Plastic liners must be used in bins for all other waste - Non-sharps waste may be disposed of via regular waste collection services 7 Moxibustion Consent of the patient is required before any treatment can take place. Moxibustion is no different. Direct scarring moxibustion is to be used only when the patient is made fully aware of the consequences of this procedure and has provided written consent for the procedure to be performed. (see sample Consent Form on page 12 of this document) Precautions for the use of moxibustion - Moxibustion techniques must be explained fully to the patient before commencement of treatment - The patient must be advised to tell the practitioner immediately if the heat sensation is too strong or intense - Extra care must be taken when treating children as they may not readily communicate any discomfort Contraindications for the use of Moxibustion - Acupuncture points contraindicated for moxibustion - High fever - Acute traumatic injury - Acute inflammatory processes - Thrombophlebitis - Abdominal and sacral region of pregnant women - Impaired skin sensation in the area of treatment - Infections and open wounds - Directly over large superficial blood vessels 8 Heat lamps and hot packs Precautions when using heat lamps or hot packs - The lam p must be steady and not in anyone s way - Electrical leads must be safely placed to prevent the practitioner from tripping - The patient s eyes must be protected from the heat - Do not over heat hot packs or wheat bags - Do not place a newly heated pack directly on exposed skin - Wrap heat pack in a towel to prevent burns to the patient when applying - The patient must be monitored at regular intervals and not left unattended for any excessive length of time (not more than 10-15 minutes maximum) 6
Contraindications when using heat lamps or hot packs - High fever - Acute traumatic injury - Acute inflammatory processes - Thrombophlebitis - Abdominal and sacral region of pregnant women - Impaired skin sensation in the area of treatment - Infections and open wounds - Directly over large superficial blood vessels 9 Cupping Precautions for cupping - As with all procedures the process must be explained fully to the patient before commencement of the cupping - The patient must be advised to inform the practitioner immediately if the procedure is too uncomfortable - The patient must be advised of the possibility of bruising - Disposable cups must be used if there is any possibility of bleeding ie cupping after needling - Glass cups may only be used over intact skin - Care must be taken not to overheat the cups before placement on the body - As long as there has been no bleeding, cups must be washed with hot water and detergent after every patient. If bleeding has occurred, then cups must be autoclaved or disposed of. Contraindications for cupping - Areas over open wounds - Oedema - Any area overlying a large blood vessel - During high fever or convulsions - Over abdominal or sacral areas on pregnant women 10 Electro-acupuncture Precautions for Electro-acupuncture - The practitioner must make sure that the apparatus is serviced and checked annually by an appropriately qualified technician - The patient must be fully advised of the procedure of electro-acupuncture prior to the commencement of treatment - The patient must be advised to inform the practitioner if the sensation is too strong or uncomfortable - Electrodes should be attached so that the current does not cross the upper body Contraindications for Electro- Acupuncture - Pregnancy however electro-acupuncture may be used for pain relief in labour - Electro-acupuncture must not be used on patients with a pacemaker 7
11 Laser acupuncture Precautions for laser acupuncture - The practitioner must make sure that the apparatus is serviced and checked annually by an appropriately qualified technician - The procedure of laser therapy must be fully explained to the patient prior to the commencement of treatment - The patient must be warned not to look into the beam produced by the laser probe as it may damage the eyes Contraindications for laser acupuncture - Laser acupuncture must not be applied to acupuncture points in immediate proximity to the eyes or to the eyes themselves - Laser acupuncture must not be applied to abdominal points during pregnancy 12 Bloodletting and using a dermal hammer Precautions for bloodletting or using a dermal hammer - The procedure must be fully explained to the patient before commencement of treatment - Single use lancets or dermal hammers must be used - Single use disposable cups must be used for bloodletting - Single use gloves must be worn by the practitioner when dermal hammering or bloodletting - An impervious single use liner must be used on the treatment table to prevent bleeding onto regular linen Contraindications for bloodletting or dermal hammer - Bloodletting and/or dermal hammering is not appropriate treatment for those with a weak constitution such as the very elderly - Bloodletting and/or dermal hammering must not be applied during pregnancy - Bloodletting and/or dermal hammering must not be applied to those with bleeding disorders or those on blood thinning medication such as aspirin, warfarin or clopidogrel 13 Thread embedding Whilst thread embedding has not been used extensively in New Zealand, it is becoming more popular in China and Korea and increasingly here as well. Many of those trained overseas do include it in their practice. Precautions for thread embedding - Practitioners who wish to use thread embedding techniques must notify the Acupuncture NZ office where a register of these practitioners will be maintained. Acupuncture NZ members will need to provide details of the date and place of training in this technique - The procedure, including risks, must be fully explained to the patient before commencement of treatment - Practitioners must obtain a signature of informed consent before commencement of the treatment (see sample Informed Consent form on page 12 of this document). - Practitioners must only use pre-sterilised single use thread embedding pack - All instructions on the pack must be rigorously followed 8
- Any threads or needles not used on one patient must not be used on another and must be appropriately disposed of - Full instruction regarding caring for the area where the thread embedding has been used must be provided to the patient in writing - Patients must be monitored daily by the practitioner for the time that the threads remain in place - Should there be any sign of infection appropriate action must immediately be taken. This may include the administration of herbal formulae both topically and/or orally or referral to the patient s GP for a course of antibiotics. Contraindications for thread embedding - Thread embedding is not an appropriate treatment for those with a weak or compromised constitution such as the very elderly or those with weakened immune systems - Thread embedding must not be applied during pregnancy - Thread embedding must not be used on children under the age of 16 - Thread embedding must not be applied to those with bleeding disorders or those on blood thinning medication such as aspirin, warfarin or clopidogrel 14 Herbal preparations All herbal preparations must be clearly labelled with the name of the formula, name of patient, date of prescription and instructions as to administration. Precautions when prescribing herbal preparations - Practitioners must refer to clinical materia medica texts for individual herbs or formula precautions - The patient should be questioned about any known allergies to food groups, plant or animal products - Consideration must be given to the patient s constitution as well as the presenting condition or illness - Pregnancy - Pharmaceuticals: efficacy may be inhibited or enhanced by herbal preparations. In particular, take precautions with patients who may be taking anticoagulants, antidepressants or anti-hypertensives. Contraindications when prescribing herbal preparations - Practitioners must refer to clinical materia medica texts for individual herbs or formula contraindications. 15 Medicinal patches Before use: - Warn the patient of possible skin irritation - Advise the patient to leave the patch on initially for 2-3 hours to ascertain skin reaction - If skin irritation occurs, instruct the patient to remove the patch - If the patch is difficult to remove, soak it with water or with alcohol - Inform the patient not to wear the patch when sleeping - prolonged exposure to the patch may cause skin irritation Precautions when using medicinal patches - Medicinal patches should not be used on a part of the body affected by oedema. 9
- Medicinal patches may not be appropriate for use on elderly patients whose skin is thinner and more fragile - People who are susceptible to allergic reactions should test the medicinal patch on a small area of skin before using Contraindications when using medicinal patches Medicinal patches are not appropriate for use in the following situations: - On any body part affected by oedema - On dry, infected or irritated skin - Children under the age of 6 - During pregnancy - Where there is acute inflammation such as in the 24-48 hours following trauma - NEVER combine a liniment with a medicinal patch, as chemical burns may result 10
16 Injury to organs signs, symptoms and possible causes Lungs Liver and Spleen Kidneys Brain and Spinal Cord Organ Signs and Symptoms Possible Causes Pain Too deep insertion at (GB21 Cyanosis (lips, fingernails) Jianjing) and other thorax points. Shock symptoms Insertion at an inappropriate angle. Epileptic fit History of lung problems. Dyspnea Pneumothorax is the most common Restricted or decreased chest mechanical adverse event from movement on the affected side incorrect needle depth that Rapid, weak pulse requires medical intervention. Onset of signs and symptoms may Pain occurs (often under the occur several hours after scapula) on the affected side. treatment. Hypotension Pale face/nails Dizziness Bruising Pain radiating towards the back Constriction of abdominal muscles (peritonitis) Shallow breathing Shock Localised back pain Blood in urine Headache / migraine Nausea Vomiting Sudden flash of pain like an electric shock post-treatment Hypotension Shock Usually a result of incorrect needle depth at thorax points in the vicinity of the Liver and Spleen. For example: LV 13 Zhangmen, LV 14 Qimen, SP 21 Dabao, GB 25 Jingmen, GB 26 Daimai,, UB 18 Ganshu. Incorrect needle depth over kidneys Management - Remove the needle - Apply first aid - CALL 111 for an ambulance - Keep the patient calm - Once the patient is safe complete an Incident Report and forward it to the Acupuncture NZ office - Follow up with the patient later that day or the next day 11
17 Incident Reporting form Incident Report Date: Practitioner Name: Time: Clinic Name: Clinic address: Patient Information Patient name: Patient date of birth: Patient contact details: Nature of accident or injury: Action taken: First aid Referral to GP Referral to ED Other (please describe) Full description of how the incident occurred: (please use additional sheet if necessary) What could have been done to prevent the incident from occurring? Follow up with patient: Practitioner signature: Date sent to Acupuncture NZ: Date received by Acupuncture NZ: 12
18 Informed consent form specified conditions Acupuncture NZ Informed Consent Specified conditions: Dermal Hammering, Gua Sha, Thread Embedding Scarring Moxa, Bleeding. This form is to be signed by the patient when any of the five procedures listed below are to be included in the treatment provided. It must be presented to the patient for signing after the procedure has been fully explained to and understood by the patient and prior to treatment commencing. Dermal Hammering Gua Sha Thread Embedding Scarring Moxa Bleeding (practitioner to circle appropriate treatment) The procedure circled above has been fully explained to me and I give my consent to the practitioner to administer this procedure. I understand that I have the right to clarify, question or stop the treatment at any time. Patient name. Patient signature. Practitioner name.. Practitioner signature.. Date:.. 13